Foster Carers' TSD Standards covered:

Author Details

Name: Grace Bowmer

Job Title: Honorary Assistant Psychologist

Specialist Therapy: N/A

Current place of work: PAFCA and The Child Psychology Service, Lichfield

So what do we know about the therapies out there for fostered and adopted children? Anecdotally, Dyadic Developmental Psychotherapy (DDP) is one of the therapies that appears to be effective but do we have anything more scientific to tell us whether it works on a larger scale?

DDP is an attachment theory based therapy that was developed by Daniel Hughes (1) . It was designed as an intervention for children who have suffered Developmental Trauma­­. As the therapy is still in its infancy, the evidence base for its effectiveness is unfortunately somewhat limited. However, two studies by Arthur Becker-Weidman offer a promising start in the development of an evidence-base for its efficacy .

First Research Study

The first study (2) Art Becker-Weidman aimed to investigate the outcomes of using DDP with children with “trauma-attachment disorders”. The investigation focused particularly on the differences between DDP and what he refers to as “traditional, optimal sound clinical work”: Cognitive-Behavioural Psychotherapy, behavioural approaches or structural family therapy interventions. A notable difference of DDP as compared to these other approaches is the emphasis placed upon the development and maintenance of strong, emotionally attuned relationships between clinician, caregiver and child.

The researchers predicted that DDP would be effective in several areas.

That the children in the treatment group would show a reduction in the symptoms of their Attachment Disorder, as shown by decreased scores on an Attachment Disorder questionnaire (3). This required the caregiver to select, from a scale of 1 to 5, how often their child engages in certain behaviours.

That the treatment group would show decreases on a number of scales on a standardised measure of emotional and behavioural problems (4). These scales measured how withdrawn, depressed, anxious and aggressive the children were and what level of social and thought problems, they had. For example, reductions in withdrawal should represent an increased ability of the child to use their caregiver as a secure base; a decrease in social problems should represent improvements in the ability to form relationships. This checklist is completed by caregivers in terms of their child’s behaviour.

The sample consisted of 64 subjects – 34 in the DDP treatment group and 30 in the control group, who were evaluated but given no further treatment.

Children were chosen for participation in the study based on a number of criteria most notably the following:

Children had a considerable history of physical abuse, neglect, sexual abuse or institutional care.

The children ranged from 5 to 16 years of age, and were either adopted or residing in foster care. In order to suitably determine that the emotional and behavioural differences between fostered and adopted children would not affect the results of the study, Becker-Weidman compared their initial scores on the attachment questionnaire and the measures of behavioural problems . He found no significant behavioural or attachment differences between fostered and adopted children, and thus it was assumed that they were similarly disordered and thus would respond similarly to treatment. Likewise, pre-test measures were also used to compare the treatment and control groups prior to the intervention. These found no significant differences between the groups on any measure, aside from Thought Problems which was higher in the treatment group. This suggests that the children in the treatment group had slightly more difficulties than those in the control group. DDP was provided to the treatment group by one therapist within an outpatient setting and an average of 23 sessions were received over 11 months.

The results of the study were very promising. Statistical tests were conducted in order to make comparisons between the different sets of data obtained within the study. Comparisons of pre-treatment scores with post-treatment scores for those within the treatment group found a significant positive difference i.e. the DDP treatment group improved as a result of the therapy. This strongly suggests that the DDP treatment was useful in reducing the behavioural problems associated with Reactive Attachment Disorder. Conversely, tests comparing scores obtained from the children in the control group both before and after the experiment showed no significant changes. That is, no improvements in behaviour were found in those who did not receive treatment.

A follow-up comparison was made between the two groups after an average of 1.2 years following the completion of treatment and evaluation. The only comparison that did not demonstrate a marked difference between treatment and control groups was the measure of problems associated with depression and anxiety. It should be noted that, by the time this comparison was made, 53% of the control group subjects had entered into what is referred to as ‘usual care’ treatments. Here, ‘usual care’ refers to the interventions of individual therapy, family therapy, play therapy, residential treatment and intensive outpatient treatment that are commonly received by individuals.

The results of this study suggest that DDP is more efficacious in the treatment of children with “trauma-attachment disorders”, as defined by a diagnosis of Reactive Attachment Disorder, than the ‘usual care’ offered to intervene in the cases of such disorders.

One possible limitation, however, is that the relative numbers of children receiving each ‘usual care’ treatment were quite low. For example, only one individual entered into a residential treatment centre, and just 9 into individual therapy (the most utilised ‘usual care’ treatment within the investigation). Therefore although it may be possible from the results to conclude the effectiveness of DDP in this instance, we can’t say that if we had larger groups of the other treatment options that they would not be effective too.

Follow-Up Research Study

The second study was a follow-up of the same groups of children (5) and this aimed to work out whether DDP could be effective over the long term. Approximately four years after the end of the initial study participants were contacted again. Of those who had previously participated, 24 of 34 in the treatment group and 20 of 30 in the control group took part in the follow-up. By this stage, all control group subjects had entered into non-DDP treatments with an average of 50 sessions each , 42% of the treatment group also received further treatment following their completion of DDP; however, most of this was for conditions that occurred alongside the Attachment Disorder such as bipolar disorder and attention deficit/hyperactivity disorder (ADHD,), rather than for treatment of the Attachment Disorder itself. The majority of this treatment occurred through medication management.

Comparisons were made between scores taken at the end of the previous study (approximately 1.2 years following treatment), and at the time of the new study (approximately 4 years following treatment). These comparisons showed that the children who had received DDP continued to demonstrate significant behavioural and attachment-related improvements even four years following treatment. The same improvement was not seen in the control group, however. These children, all of whom had been undergoing various ‘usual care’ treatments, actually showed overall deteriorations in their behaviour after the four years. These were accompanied by small but significant increases in certain behavioural measures: symptoms of anxiety/depression, problems with attention, instances of rule-breaking behaviour, and aggressive behaviour. These results are particularly concerning as all children within the control group received ‘usual care’ treatment of some form during the four-year period, yet on average their behaviour appears to have declined. This provides further evidence that these treatment methods may not be effective for children with Reactive Attachment Disorder.

The results of this study confirm the effectiveness of DDP in treating “trauma-attachment disorders”, in addition to demonstrating that its effects remain for at least four years following treatment. Such effects are displayed through a reduction of attachment disorder symptoms and changes in numerous behavioural measures, such as reduced aggression and an increase in socially acceptable behaviour.

As the primary difference between DDP and the other treatments in these studies is a focus upon developing and maintaining strong, emotionally attuned relationships between clinician, caregiver and child, it is hypothesised that this is the reason for its differential effectiveness within this study. This may well be an area for further research, which could seek to measure the bonds between all concerned, particularly the attachment between caregiver and child, and make comparisons with other therapies.

Caregivers views about their child’s attachment behaviour were also collected before and after treatment for those in the treatment group. Prior to treatment, children showed little evidence of seeking comfort or care from their caregiver. Following treatment, however, a considerable increase in such behaviour was reported. Additionally, caregivers of those in the treatment group reported more positive emotional relationships with the children in their care, which included more genuine displays of affection. Although this is anecdotal evidence rather than a change that has been scientifically measured, this is surely compelling evidence towards improved attachments of those in the treatment group.

In the future it will be important to test these findings and replicate the study with another group of children to determine whether the success is consistent. One possible limitation of the follow-up study is the reduced sample size by approximately one third. It may also be the case that those who struggled behaviourally or in terms of attachment following DDP may have been less inclined to respond to the questionnaire, and thus the follow-up results may not be truly representative of the original sample. Additionally, it is important to note that the DDP within this study was provided by only one therapist. It is necessary to take the efficacy research forward by testing whether the results seen in these studies can be replicated by different therapists and whether it is stable across providers.

It is also significant to consider the effects that medication management may have had on those within the treatment group, as it is not possible to comprehensively state that treatment for co-morbid conditions such as ADHD would have no effect upon the behavioural measures that were taken.

Although DDP itself requires further robust evaluation to develop a strong evidence base, it is a combination of several different other approaches and methods which themselves have a wealth of supporting evidence (e.g. 6).

PAFCA's DDP Effectiveness Top 5 Tips

When embarking on therapy with your child don’t be afraid to ask about the evidence base for the treatment you are being offered.

Given that treatments for Developmental Trauma and/or Reactive Attachment Disorder are still relatively new your provide may not be able to produce evidence in the form of scientific literature. If they cannot then they should still have a sound rationale based on your family’s individual circumstances, your child’s history and the theoretical information available as to why they are recommending any particular therapeutic approach.

The fundamental principles of DDP informed parenting are Playfulness, Acceptance, Curiosity and Empathy, summarised by the acronym PACE.

If you want to explore DDP further for your child you can visit the DDP institute’s website http://www.dyadicdevelopmentalpsychotherapy.org. DDP practitioners in the UK are currently developing a website which will provide more comprehensive and local information about DDP. We will update these details as soon as we have them.

In the absence of direct DDP, you can employ the principles in your parenting see Hughes and Golding (7).